B-2018-1223 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1223
20273 NORTHCOVE SQ CUPERTINO,CA 95014-0505(316 41 041) ATICINSON
CLIMATROLLERS INC
SAN JOSE,CA 95112
OWNER'S NAME:Fung Michael G And Tracie C Trustee DATE ISSUED:07/19/2018
OWNER'S PHONE: PHONE NO:(408)294-6290
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C20 Lic.#258540
Contractor ATKINSON CLIMATROLLERS INC Date 12/31/2018 X BLDG_ELECT_PLUMB
I hereby (firm that I am licensed under the provisions of Chn ter 9 X MECH X RESIDENTIAL_COMMERCIAL
a p p (commencing
with Section 7000)of Division 3 of the Business&Professions Code and that my
license Is in full force and effect. JOB DESCRIPTION:
INSTALL DUCTLESS MINI-SPLIT SYSTEM
I hereby affirm under penalty of perjury one of the following two declarations:
r, I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 ofthe Labor Code,for the
FKperformance of the work for which this permit is issued.
have and will maintain Worker's Compensation Inset once,as provided for by
Section 3700 ofthe Labor Code,for the performance ofthe work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$16000.00
APPLICANT CERTiFPCATiON
I certify that I have read this application and state that the above
information Is correct.I agree to comply with all city and county ordinances APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 31641 041
representatives of this city to enter upon the above mentioned properly for
inspection purposes.(We)agree to save indemnify and keep harmless the
City of Cupertino against liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORI{IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the�e(ip an understand anfi�,' ill.e ply with all non-point
source regul fans p the Cope M diel al o ,section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature to 07/19/201 8 Issued by:Jasmine Archbold
Date:07/19/2018
OWNER- UILDER DECLARATION
I hereby affirm that I am exempt train the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If. or is
r. 1,as owner ofthe property,or my employees with wages as their sole installed without first obtaining an inspection,l agree to remove all new materials for
compensation,will do the work,and the an neftne is not intended or offered for inspection.
sale(Sec.7o44,Business&Professions Code)
x. I,as owner of due property,am exclusively contracting with licensed Signature ofApplicei t:
contractors to construct the project(See.7044,Business&Professions Code). Date:07/19/2018
1 hereby affirm under penalty of'perjury one ofthe following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. 1 have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance ofthe work for which this per is issued, HAZARDOUS MATERIALS DISCLOSURE
1. 1 have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazm-deus matm9ots requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for tine performance of the work far which this California Health&Safety Code,Sections 25505,25533,and 25534.I will
permit is issued, maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
3. 1 certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(n)should I store or handle hazardous
shall not employ may person in any manner so as to become subject to the material.Additionally,should 1 use equipment or devices which emit hazardous
a1r contaminants as defined by the Hxy Area Air Quality M,aP.it�.,, at District I
Worker's Compensation laws ofQalbiends.If,after making this certificate of wilt maintain compliance with B Ci trim.Municipal are, hapteer^9. and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety C de, @'tions 25505, 53 d 554.
Labor Code,l must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent, _
APPLICANT CERTIFICATION Date:07/19,-.,—
I certify that I have read this application and state that the above information Is CONST CTT LE G AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in Lender's Address
consequence ofthe granting of this permit.Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DF,-LARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Date 07/1912018 Licensed
Professional